Managed Care Flashcards
Why do we care about Managed Care?
Healthcare is expensive and increasing in expense
National Health Expenditures per Capita in US
- US has continued to increase there health expenditures per capita over the years to 14,944$
- US has continued to increase there health expenditures as % of GDP over the years to 19.3%
History of Life Expectancy
Female > Male
- life expectancy in 1960’s were very low around 65-72
- life expectancy began to increase throughout the years
- life expectancy from 2003 to 2020 lost two decades of progress from COVID19, opioids, and firearms
What is Managed Care?
delivery of healthcare services in a way that puts LIMITED RESOURCES TO BEST USE in optimizing patient care
Characteristics of Managed Care
- highly regionalized (insurance is regulated by states)
- molded by territorial demands
- varied based on employer size
- used by both private and public health plans
What do Managed Care Organizations include?
- Managed Medicaid and Medicare programs
- Employer offered commercial insurance plans
- Department of Defense TRICARE
focus is on controlling costs by controlling supply and demand of healthcare resources
Health Maintenance Organizations (HMO)
- expanded following the HMO Act of 1973
- promote wellness and health prevention along with acute/chronic care
Why have HMOs fallen out?
- if you are apart of an HMO, you have to use HMO physician which decreases the patients choice of providers
- individuals are less likely to stay with same provider throughout their career
Most popular HMO
Kaiser Permanente
Goals of Managed Care
- prevention of disease
- focus on wellness and enhanced QOL
- improved clinical outcomes
- quality/accessibility of health care
- COST CONTAINMENT
Managed Care Pharmacy Tools
Formulary development
Medication Therapy Management
Prescription drug monitoring programs
Drug Utilization Review
Utilization Management:
- manage formularies
- prior authorizations
- step therapy
- quantity limits
Preferred & Exclusive Networks
Mail Order Pharmacy
Speciality Pharmacy
Tiered Formulary
- design that financially rewards patient for using generic or preferred drugs by increase copayments of higher tier medications
Tier 1: preferred generic
Tier 2: non-preferred generic
Tier 3: preferred brand
Tier 4: non-preferred brand
Tier 5: preferred speciality
Tier 6: non-preferred speciality
Percentage of Firms and Workers offering health benefits
the smaller the firm or business, the lower percentage of health benefits offered to workers
Distribution of Health Plan Enrollment
Conventional plans have decreased over the years
HMO plans have decreased over the years
PPO/POS plans have stayed relatively consistent over the years
High-Deductible Heath plans have increased over the years
Premier CDHP
highest premiums
lowest deductibles
lowest out-of-pocket maximum
Standard CDHP
middle of the road premiums, deductible, and out-of-pocket maximum
Limited CDHP
lowest premiums
highest deductible
highest out-of-pocket maximum
All 3 CDHP contain
- same nationwide network of providers
- free preventative care with Tier 1 or Tier 2 provider
- free generic preventative medications
- HSA contributions (200$ single; 400$ family)
Process of Purdue Health Plan
- Pick CDHP
- Patient pays full cost of services before deductible
- can use HSA or Flexible Spending Account - After deductible is met, you and Purdue share costs (coinsurance)
- After out-of-pocket maximum is met, you pay nothing for covered services for rest of year
Cost of Health Plans with family
as you add children and spouses, your cost for health plan and premiums increase compared to single coverage
How often are formulary changes made?
quarterly
Average Annual Worker and Employer Contributions to Premiums
- both the employer & the workers are paying more in premiums as HC increases
- employers contribute more to premiums than workers
Changes in Premiums, Inflation, and Earnings for Family Coverage from 2003-2023
- From 2003-2018, premium prices were increasing at a much higher rate than workers earnings and inflation
- 2018 to 2023, workers earnings have increased slightly more than premium prices
- DEDUCTIBLES ARE INCREASING AT MUCH HIGHER RATES THAN PREMIUMS, INFLATION, AND WORKERS EARNINGS
Conceptual Model of flow of products
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AMCP
Academy of Managed Care Pharmacy
Why is Population Health & Managed Care important to Pharmacists?
- population is living longer
- OVERUTILIZATION OF HEALTHCARE SERVICES
- Greater % of population eligible for Medicare/Medicaid
- impact of HC costs on federal budget
- new technologies increasing costs without evidence of better outcomes
Health Insurers with PBMs
CVS Health –> Caremark PBM
- acquired Aetna
Cigna –> Express Scripts PBM
United Health –> Catamaran and Optum PBM
